I
Revenue Cycle Management
01
US Healthcare Revenue Cycle Management
The US healthcare revenue cycle management (RCM) system oversees the financial processes of patient care, from registration and insurance verification to claims submission, payment collection, and compliance reporting. It ensures providers receive timely reimbursements while managing challenges like complex billing codes, regulatory changes, and increasing patient payment responsibilities. Emerging trends, including automation, telehealth billing, and patient-centric approaches, aim to streamline operations and improve financial outcomes, enabling providers to focus on delivering quality care.
Physician Credentialing
02
Physician Credentialing is the process of verifying a physician’s qualifications, including education, training, experience, licensure, and certifications, to ensure they meet the standards required to provide medical care. This process is essential for granting hospital privileges, enrolling in insurance networks, and maintaining compliance with regulatory standards. It safeguards patient safety by ensuring healthcare providers are qualified and competent.
03
EDI Set Up
EDI (Electronic Data Interchange) Setup refers to the process of establishing a secure and automated system for exchanging standardized business documents electronically between healthcare providers, payers, and other entities. In healthcare, EDI is commonly used for transmitting claims, eligibility inquiries, payment remittance, and other transactions in HIPAA-compliant formats.
Prior Authorization Process
04
The prior authorization process is a requirement by insurance payers to approve specific medical services, procedures, or medications before they are provided to ensure medical necessity and coverage. It involves submitting a request with supporting documentation, payer review, and either approval or denial based on clinical guidelines and policy criteria. If denied, providers can appeal with additional information. Upon approval, an authorization code is issued for billing. While the process ensures cost management and policy adherence, it can be time-intensive, prompting efforts to streamline it through automation and improved workflows.
05
Insurance Verification
Insurance verification is the process of confirming a patient’s insurance coverage and benefits before providing medical services. It ensures that the provider is aware of the patient’s policy details, including active coverage, co-pays, deductibles, coverage limits, and authorization requirements. This step reduces the risk of claim denials, billing errors, and unexpected out-of-pocket costs for patients. Insurance verification typically involves checking with the payer directly or using online tools to validate eligibility and benefits, ensuring a smoother billing and reimbursement process.
Medical Billing and Coding
06
Medical billing and coding are essential processes in the healthcare revenue cycle, translating patient care into billable claims for reimbursement. Medical coding involves assigning standardized codes to diagnoses, procedures, and treatments using systems like ICD-10, CPT, and HCPCS. These codes ensure accurate documentation of services provided. Medical billing uses these codes to create and submit claims to insurance companies, manage payments, and address denials or rejections. Together, these processes ensure healthcare providers are compensated efficiently while maintaining compliance with regulatory and payer requirements.
07
Payment Posting
Payment posting is a critical step in the healthcare revenue cycle where payments received from insurance companies, patients, or other entities are recorded in the provider’s billing system. This process provides a detailed overview of account statuses, including claims paid, underpaid, or denied. Accurate payment posting ensures proper allocation of funds, identifies discrepancies or payer issues, and helps initiate follow-ups for underpayments or denials. It also enhances financial transparency and streamlines the reconciliation process, contributing to efficient revenue management.
Account Receivable MGM
08
Account Receivable Management Services
Account Receivable (A/R) Management Services in healthcare focus on optimizing the collection of outstanding payments from patients, insurance companies, and other payers. These services involve monitoring, tracking, and following up on unpaid claims to ensure timely payments. Key tasks include managing aging reports, addressing denied or underpaid claims, negotiating with insurers, and communicating with patients about outstanding balances. A/R management ensures the financial health of healthcare providers by improving cash flow, reducing bad debt, and ensuring that all claims are paid in full and on time.
09
Transition Process Flow
The transition process flow is a structured approach used to smoothly move from one phase, system, or state to another, minimizing disruptions and ensuring continuity. It typically involves planning and preparation, assessing and documenting current conditions, executing the planned changes (such as system migration or team restructuring), and monitoring progress to address any issues. Afterward, a review and optimization phase ensures that the transition is successful, with improvements made where needed. Proper transition management facilitates seamless integration of new processes or systems, ensuring long-term success and efficiency.